Friday, September 1, 2017

What works and who benefits: Treating behavioral problems in kids on the Autism Spectrum

Sometimes kids can be challenging. They forget rules they've learned, and don't listen to their parents. These types of problems happen with all children, all over the world, but can be even more challenging for parents with kids on the Autism Spectrum. Luckily, this is a problem that psychology is very good at solving. For decades, leaders in the field of behavioral science have been developing and perfecting intervention programs for children with Autism Spectrum Disorders. 

In clinical psychology and medicine, the best way to show that an intervention works is by conducting a randomized controlled trial (RCT). In this type of clinical trial, a team of researchers recruit a sample of individuals in their target population and randomly assign them to one of two or more interventions. Using this scientific approach is the only way of knowing at the end of the intervention whether the improvements you observed were due to the intervention, rather than differences between the individuals in the treatment groups. 

Very recently,  Karen Bearss, Emory University, and her research team published the results of the largest RCT ever conducted looking at the effectiveness of two active treatment programs for disruptive behavior in children on the Autism Spectrum. They compared Parent Training (PT) and a Parent Education Program (PEP) to determine which program resulted in the greatest improvements in disruptive behaviors. Parent Training is described as follows: 

"The first session taught parents to identify the function of a behavior by analyzing its antecedents (events occurring before the behavior) and consequences (events following the behavior). Subsequent sessions presented strategies for preventing disruptive behavior (eg, visual schedules for routine events), positive reinforcement for appropriate behavior, planned ignoring of inappropriate behavior, and techniques to promote compliance. In the last few sessions, the therapist instructed parents on teaching new skills (eg, communication or daily living skills) and how to maintain improvements over time. This sequence was intended to reduce the child’s disruptive behaviors and foster skill acquisition. The treatment sessions used direct instruction, video examples, practice activities, and rehearsal (role play) with feedback to promote parental skill acquisition. In homework assignments between sessions, parents applied new techniques to specific behaviors. 

The other treatment arm, Parent Education Program, involved having a trained therapist provide "useful information on young children with ASD, including the essentials of evaluation, developmental changes in ASD, educational planning, advocacy, and current treatment options." Each intervention arm included 11 or 12 sessions, and sessions in both treatment arms were 12 60-90 minute sessions. They measured improvements in child defiant behaviors, aggression, irritability, social withdrawal, stereotypy, hyperactivity, and inappropriate speech 24 and 48 weeks after starting the treatment program.  Each of these are core behavioral problems that children on the Autism Spectrum and their families commonly deal with on a daily basis. 

The trial ultimately randomized 180 children (ages 3-7, 158 boys, 22 girls) on the Autism Spectrum to one of the two treatments. Twenty four weeks after starting the treatment program, kids assigned to the PEP showed a 31.8-34.2% decline in behavior problems, depending on the behavior examined. Kids assigned to PT showed a 47.7-55% decline in behavior problems. In other words, both treatments worked in reducing problem behaviors, but the Parent Training program worked much better. Further, the benefit of these treatment programs were still visible at the 48 week follow-up. The research team concluded that Parent Training is an effective program for addressing disruptive behaviors in families with children on the Autism Spectrum. 

More recently, this research team published a study of the moderators of treatment response. Moderators are factors that influence how well the treatment program works. In this study, Luc Lecavalier, Ohio State University, looked at whether the Parent Training intervention works better or worse in kids with different individual or family characteristics. For example, they looked at whether IQ of the child, severity of Autism, presence of another co-occurring disorder such as ADHD or anxiety,  living in a single parent family, or parent income and education were related to treatment outcomes. 

They found that the kids who improved the most from Parent Training were the ones without co-occurring ADHD, low anxiety symptoms, and living in families with a family income above $40,000 per year. In other words, there was no difference in benefit from PT or PEP for kids in the study with ADHD, high symptoms of anxiety, or in low-income families. That being said, the PEP was still associated with a 31-34% decline in disruptive behaviors, so treatment was still somewhat effective. 

To their surprise, the research team did not find that IQ or severity of Autism symptoms were associated with differences in treatment benefits from Parent Training. This is important because many people believe that IQ and symptom severity automatically mean that treatments won't work for them. Here, we see that kids in the study with a range of IQ and symptom severity showed improvements in disruptive behaviors, particularly those enrolled in Parent Training. 

So what does this mean? If you have a child on the Autism Spectrum, Parent Training may significantly improve your and your child's quality of life. In fact, Parent Training is a well-established and effective way of dealing with disruptive behaviors for kids (up to around age 12), regardless of being on the Autism Spectrum. The strategies taught to parents in Parent Training are based in basic behavioral science and apply to all behavior, and in these treatment programs the principles of behavioral theory are simply tailored to the most commonly observed problems in specific populations. 

A final thought on the name "Parent Training." In my work, I've found many parents resistant to going through training in parenting. In many ways, it seems as though parenting should be intuitive and not, yet another, thing that requires a degree or certification. In many ways that's very true. Loving and caring for a child is innate. Teaching a child to regulate their impulses and emotions is something entirely different, and often at odds with the immense loving and caring you feel for them. Think about how often you, as a parent or caregiver, feel conflicted between the short-term relief of "peace and quiet" that is almost immediately gained from giving in to a toddlers request for something at the grocery store and the long-term benefit of not hearing these requests every time you go to the store until the end of time. Behavioral science is an immense field of study that resulted in the training of the modern generation of clinical psychologists who can provide Parent Training that will help reduce the impact of these little moments in your daily life. 

If you're interested in learning more, some Parent Training books I highly recommend for parents looking for behavioral strategies that work: 

For all parents: 


For the over-achievers out there, Alan Kazdin has also just completed a course on parenting in Coursera called "Everyday Parenting" which I highly recommend for anyone who has or will ever have kids.   Click here to learn more about that course. 

For parents struggling with child defiance: 

The Kazdin Method for Parenting the Defiant Child by Alan E. Kazdin

Your Defiant Child, Second Edition: Eight Steps to Better Behavior by Russell A. Barkley and Christine M. Benton

Bearss, K., Johnson, C., Smith, T., Lecavalier, L., Swiezy, N., Aman, M., ... & Sukhodolsky, D. G. (2015). Effect of parent training vs parent education on behavioral problems in children with autism spectrum disorder: a randomized clinical trial. Jama313(15), 1524-1533.

Lecavalier, L., Smith, T., Johnson, C., Bearss, K., Swiezy, N., Aman, M. G., ... & Scahill, L. (2017). Moderators of parent training for disruptive behaviors in young children with autism spectrum disorder. Journal of abnormal child psychology45(6), 1235-1245.

Many thanks to for the lovely photos! 


  1. Such a helpful post! I only learned until my son turned 5 that he is suffering from autism and it was hard for me to handle him in a different way...I wanted to make him feel normal just like the other kids.

  2. It is very challenging to handle an Autistic child but it can be manageable if properly taken care of all things told by psychologist.


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